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The Match is Moving Leaving Geriatrics and Palliative Care Behind

The word on the street is that the National Resident Matching Program (NRMP) will shortly announce that as of 2012, the medical specialties fellowship match is being pushed back to the middle of PGY3 year. Interviews for medical specialty fellowships will now occur over the summer and fall of their PGY3 year, match lists will be due on November 21st, and subspecialty match results will be released on December 5th.

This is welcome news for residents as they will now have significantly more time to decide whether they want to pursue a specialty career, to advance their scholarly projects and professional development, and to interview in programs across the US during their third year. This new time schedule is very learner centric and should be applauded.

However, there are two medical specialties that continue to hold out in putting learners first when it comes to recruitment. Unfortunately, these specialties are Hospice & Palliative Medicine and Geriatrics. These two fellowships are among the few specialty fellowships that do not partake in the match. They will therefore continue to ask interns and residents to make decisions early on in their residency that they would not have make if they entered into cardiology, gastroenterology, oncology, or nephrology. For instance, our fellowships at UCSF in Geriatrics and in Hospice & Palliative Care will both be filled within the next month for the July 2012 academic year. This means that residents will need to complete their applications early in their PGY2 year, just to compete with other applicants from across the US.

Why would two specialties that are nearly synonymous with quality of life and patient centeredness be so opposed to being learner centric in recruitment? These specialty programs are in general nervous to compete nationally for fellows. As Gavin Hougham from the Hartford Health AGEnda wrote in a recent post:

"programs tend to recruit from within their own institutions. The field seems to hold a perception that geriatric medicine fellowship recruitment is so unique, extraordinary, or “exceptional,” that recruitment can only be done by hand, one by one. Unfortunately, there is another way to look at exceptionalism. Some program directors will admit that they fear geriatric medicine is such an unattractive sell as a medical specialty that to get any takers at all they must hover over and wall off their own internal prospects as early as possible, quietly ushering them into their own programs."

Current evidence suggests that participating in a match is good for residents and good for programs. An excellent case example is gastroenterology. GI fellowships stopped participating in the match in 1999. For the next 7 years, the GI subspecialty application process became chaotic with interviewing schedules creeping earlier in the PGY-2 year as fellowship programs attempted to outmaneuver each other. Even worse, applicants were given sometimes only hours to days to accept offers from programs that just interviewed at, limiting any ability to consider other programs to which they had applied but not yet interviewed. Applicant mobility decreased and as well as satisfaction with their subsequent choices. In 2006, GI reinstated the match. By 2008, 97% of participating program directors judged that reinstitution of the match was good for the future of their specialty.

The good news is that both geriatrics and palliative care are considering instituting a match, although significant hurdles remain as many programs remain hesitant to participate. The new changes to the medical specialties match should give us all a renewed commitment to making the recruitment process learner centric. Honestly, with all due respect to my cardiology and gastroenterology colleagues, are we really going to be bested by them when it comes to being the nice guys & girls on campus?

by: Eric Widera

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Thanks Eric - Even though I have sat in on more "discussions" of the match at meetings of the Association of Directors of Academic Geriatrics Programs than I can count, I can't say that I really understand this issue.

Clearly some fellowship programs do very well right now and see little reason to change. On the other hand there were only 273 first year fellows for the 480 ACGME slots as of December 2009, so the majority of programs have been scrambling/failing to fill positions. I know that some fill very very late, sometimes with people who are using geriatrics as a "back-up" plan if they don't get into a more popular specialty. Perhaps moving the match later in residency training will work better for these programs who's primary concern is filling.

I wonder also how this policy change might interact with the ideas we were kicking around on HealthAGEnda about an early recruitment award aimed at residents to draw them into careers in academic geriatrics. http://www.jhartfound.org/blog/?p=3110

It seems really bad for the disciplines of Geriatrics and Palliative Medicine to have such a different fellowship selection process than other specialties.

In particular, a process in which residents are forced to apply for fellowships in these disciplines earlier than they would have to apply in other disciplines could make the fellowships less attractive to residents.

We really shouldn't accept arguments for the status quo that are framed in terms of the convenience of the fellowship programs. Are there any reasonable arguments as to why the status quo is better for potential applicants? If not, it is time for our fellowship programs to get onboard with the match.

The fellowship that I did has had a mix of people just finishing residency and physicians who had been working about 10 years who were wanting to shift gears. For those who are having to figure out ways to make the shift from work to fellowship, the longer lead time has been helpful. I'm assuming that if the pallimed fellowships were part of the fellowhsip match, you could still take folks outside of the match.

"the ... subspecialty application process became chaotic with interviewing schedules creeping earlier in the PGY-2 year as fellowship programs attempted to outmaneuver each other. Even worse, applicants were given sometimes only hours to days to accept offers from programs that just interviewed at, limiting any ability to consider other programs to which they had applied but not yet interviewed. Applicant mobility decreased and as well as satisfaction with their subsequent choices,"

it sounded eerily like what has and is creeping into the H&PM fellowship application.

Let us hope that value for the greater good for all involved carries the day, before we recapitulate the long, hard lesson that GI already learned.

The NRMP states that a specialty, whether it be palliative medicine or geriatrics, is requested to:

1) verify that at least 75% of the programs with available positions in a given year will be registered for the match,2) encourage programs to actively participate by submitting a rank order list, and3) have at least 75% of the available positions within the specialty registered with the NRMP.

So yes, you could accept applicants outside of the match, but most positions need to be match positions.

I also love the idea of a competitive “debt service” award. There are significant financial challenges for advanced training in geriatrics. Having some type of debt repayment will at least be a little bit of incentive to continue on with training.

As most, if not all, geriatrics fellowship program directors know, the Match has been the subject of ongoing discussions at the national geriatrics meetings for quite some time with plenty of strong feelings on both sides of the issue.

In hopes of putting this issue to rest one way or the other, at least for the time being, ADGAP is currently polling the program directors of all 150 fellowship programs. The question: will your program participate in the Match and if so, how many positions will you put in the Match.

The results of the poll will be shared at the business meetings of ADGAP and the ADGAP Fellowship Directors Group at this year's annual AGS meeting and will be used by the ADGAP board in its decision to recommend for or against participation in the Match.

It's worth noting that geriatrics cannot participate in the internal medicine subspecialty Match because we accept applicants from both IM and family medicine. Therefore, geriatrics would have a separate Match of its own that would also occur in the fall of the 3rd year of residency.

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